A high LDH to AST ratio >22.12 suggests that TTP is a more likely diagnosis than HELLP syndrome in the third trimester pregnant patient, presenting with findings that could be compatible with either diagnosis. In these circumstances, it is advisable to obtain hematology consultation and to consider PEX implementation.

No abstract

Laparoscopic surgical simulation is a valuable and validated training tool. We examined its perception and use among general surgery residents at our institution. Questionnaires were sent to all 29 general surgery residents with a 93 per cent response rate. Residents were divided into junior residents (JR; PGY 1–2) and senior residents (SR; PGY 3–5). JR spent more hours in the simulation center and completed their assigned tasks faster than SR (14 vs 52 days). Thirty-three per cent of SR felt that simulation training should be limited to JR in contrast to only 8 per cent of JR. However, 93 per cent of residents agreed that the program improved their laparoscopic skills. Most residents feel that simulation training is essential and mandatory in current surgical residency (75% of JR and 67% of SR) and needs to be extended to open surgery (67% JR and 60% SR). Seventy-five per cent of JR, but only 13 per cent of SR, feel that residents’ involvement in procedures should be based on performance in surgical simulation. JR ranked simulation training first in useful ways to learn new skills, whereas SR ranked proctorship highest. JR have a higher use of simulation training and a higher perception of its utility.

The clinical features of cholesterol embolism in the kidney have been well delineated.' We report a case of acute renal graft failure due to cholesterol emboli. We further suggest that fibrinolytic treatment caused the disease and draw attention to this potential complication of an increasingly popular treatment of myocardial infarction.2 3 Case report A 56 year old man was admitted to hospital with chest pain that had lasted four hours. Nineteen years earlier he had received a cadaver kidney transplant after a 20 year history of chronic glomerulonephritis with hypertension. No rejection occurred. Serum creatinine concentration was stable at 150 [smol/l. Maintenance